To achieve global targets for universal treatment set forth by the Joint United Nations Programme on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (UNAIDS), viral load monitoring for HIV-infected persons receiving antiretroviral therapy (ART) must become the standard of care in low- and middle-income countries (LMIC) (1). CDC and other U.S. government agencies, as part of the President's Emergency Plan for AIDS Relief, are supporting multiple countries in sub-Saharan Africa to change from the use of CD4 cell counts for monitoring of clinical response to ART to the use of viral load monitoring, which is the standard of care in developed countries. Viral load monitoring is the preferred method for immunologic monitoring because it enables earlier and more accurate detection of treatment failure before immunologic decline. This report highlights the initial successes and challenges of viral load monitoring in seven countries that have chosen to scale up viral load testing as a national monitoring strategy for patients on ART in response to World Health Organization (WHO) recommendations. Countries initiating viral load scale-up in 2014 observed increases in coverage after scale-up, and countries initiating in 2015 are anticipating similar trends. However, in six of the seven countries, viral load testing coverage in 2015 remained below target levels. Inefficient specimen transport, need for training, delays in procurement and distribution, and limited financial resources to support scale-up hindered progress. Country commitment and effective partnerships are essential to address the financial, operational, technical, and policy challenges of the rising demand for viral load monitoring.

Home-based VCT for household members of HIV-infected persons was feasible, associated with lower prevalence, higher uptake, and increased identification of HIV-infected persons than clinic-based provision.

Background HIV self-testing increases testing uptake in sub-Saharan Africa but scale-up is challenging because of resource constraints. We evaluated an HIV self-testing intervention integrated into high-burden outpatient departments in Malawi.Methods In this cluster-randomised trial, we recruited participants aged 15 years or older from 15 outpatient departments at high-burden health facilities (including health centres, mission hospitals, and district hospitals) in central and southern Malawi. The trial was clustered at the health facility level. We used constrained randomisation to allocate each cluster (1:1:1) to one of the following groups: standard provider-initiated testing and counselling with no intervention (provider offered during consultations), optimised provider-initiated testing and counselling (with additional provider training and morning HIV testing), and facility-based HIV self-testing (Oraquick HIV self-test, group demonstration and distribution, and private spaces for interpretation and counselling). The primary outcome was the proportion of outpatients tested for HIV on the day of enrolment, measured through exit surveys with a sample of outpatients. Analyses were on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

Aims:  To measure enteric bacterial contamination of tubewells in three flood prone areas in Bangladesh and the relationship of bacteriological contamination with tubewell sanitary inspection scores. Methods and Results:  Microbiologists selected 207 tubewells in three flood prone districts, assessed physical characteristics of the tubewells and collected a single water sample from each tubewell. Tubewell water samples were contaminated with total coliforms (41%, n = 85), thermotolerant coliforms (29%, n = 60) and Escherichia coli (13%, n = 27). Among contaminated wells, the median CFU of contamination per 100 ml was 8 (interquartile range, 2–30) total coliforms, 5 (interquartile range, 2–23) thermotolerant coliforms and 6 (interquartile range, 1–30) E. coli. There was no significant association between tubewell contamination with E. coli, thermotolerant coliforms or total coliforms and a poor sanitary inspection score, though a history of inundation was associated with contamination with both E. coli and thermotolerant coliforms. Conclusions:  Tubewells in flood‐prone regions of Bangladesh were commonly contaminated with low levels of faecal organisms, contamination that could not be predicted by examining the tubewell’s external characteristics. Significance and Impact of the Study:  The forms currently used for sanitary inspection do not identify the most important causes of drinking water contamination in these communities.

IntroductionAlthough several studies have explored factors associated with loss to follow-up (LTFU) from HIV care, there remains a gap in understanding how these factors vary by setting, volume of patient and patients’ demographic and clinical characteristics. We determined rates and factors associated with LTFU in HIV care Lilongwe, Malawi.MethodsWe conducted a retrospective cohort study of HIV-infected individuals aged 15 years or older at the time of registration for HIV care in 12 ART facilities, between April 2012 and March 2013. HIV-positive individuals who had not started ART (pre-ART patients) were clinically assessed to determine ART eligibility at registration and during clinic follow-up visits. ART-eligible patients were initiated on triple antiretroviral combination. Study data were abstracted from patients’ cards, facility ART registers or electronic medical record system from the date of registration for HIV care to a maximum follow-up period of 24 months. Descriptive statistics were undertaken to summarize characteristics of the study patients. Separate univariable and multivariable poisson regression models were used to explore factors associated with LTFU in pre-ART and ART care.ResultsA total of 10,812 HIV-infected individuals registered for HIV care. Of these patients, 1,907 (18%) and 8,905 (82%) enrolled in pre-ART and ART care, respectively. Of the 1,907 pre-ART patients, 490 (26%) subsequently initiated ART and were included in both the pre-ART and ART analyses. The LTFU rates among patients in pre-ART and ART care were 48 and 26 per 100 person-years, respectively. Of the 9,105 ART patients with reasons for starting ART, 2,451 (27%) were initiated on ART because of pregnancy or breastfeeding (Option B+) status. Multivariable analysis showed that being ≥35 years and female were associated with decreased risk of LTFU in the pre-ART and ART phases of HIV care. However, being in WHO clinical stage 3 (adjusted risk ratio (aRR) 1.35, 95% confidence interval (CI): 1.20–1.51) and stage 4 (aRR 1.87, 95% CI: 1.62–2.18), body mass index ≤ 18.4 (aRR 1.24, 95% CI: 1.11–1.39) at ART initiation, poor adherence to clinic appointments (aRR 4.55, 95% CI: 4.16–4.97) and receiving HIV care in rural facilities (aRR 2.32, 95% CI: 1.94–2.87) were associated with increased risk of LTFU among ART patients. Being re-initiated on ART once (aRR 0.20, 95% CI: 0.17–0.22), more than once (aRR 0.06, 95% CI: 0.05–0.07), and being enrolled at a low-volume facility (aRR 0.25, 95% CI: 0.20–0.30) were associated with decreased risk of LTFU from ART care.ConclusionA sizeable proportion of ART LTFU occurred among women enrolled during pregnancy or breast-feeding. Non- compliance to clinic and receiving ART in a rural facility or high-volume facility were associated with increased risk of LTFU from ART care. Developing effective interventions that target high-risk subgroups and contexts may help reduce LTFU from HIV care.